The Challenge of Global Health By Laurie Garrett

[Guest guest]

The Challenge of Global Health By Laurie Garrett

From Foreign Affairs, January/February 2007

Summary: Thanks to a recent extraordinary rise in public and private

giving, today more money is being directed toward the world's poor and

sick than ever before. But unless these efforts start tackling public

health in general instead of narrow, disease-specific problems -- and

unless the brain drain from the developing world can be stopped --

poor countries could be pushed even further into trouble, in yet

another tale of well-intended foreign meddling gone awry.

Laurie Garrett is Senior Fellow for Global Health at the Council on

Foreign Relations and the author of Betrayal of Trust: The Collapse of

Global Public Health.

BEWARE WHAT YOU WISH FOR

Less than a decade ago, the biggest problem in global health seemed to

be the lack of resources available to combat the multiple scourges

ravaging the world's poor and sick. Today, thanks to a recent

extraordinary and unprecedented rise in public and private giving,

more money is being directed toward pressing heath challenges than

ever before. But because the efforts this money is paying for are

largely uncoordinated and directed mostly at specific high-profile

diseases -- rather than at public health in general -- there is a

grave danger that the current age of generosity could not only fall

short of expectations but actually make things worse on the ground.

This danger exists despite the fact that today, for the first time in

history, the world is poised to spend enormous resources to conquer

the diseases of the poor. Tackling the developing world's diseases has

become a key feature of many nations' foreign policies over the last

five years, for a variety of reasons. Some see stopping the spread of

HIV, tuberculosis (TB), malaria, avian influenza, and other major

killers as a moral duty. Some see it as a form of public diplomacy.

And some see it as an investment in self-protection, given that

microbes know no borders. Governments have been joined by a long list

of private donors, topped by Bill and Melinda Gates and Warren

Buffett, whose contributions to today's war on disease are mind-boggling.

Thanks to their efforts, there are now billions of dollars being made

available for health spending -- and thousands of nongovernmental

organizations (NGOs) and humanitarian groups vying to spend it. But

much more than money is required. It takes states, health-care

systems, and at least passable local infrastructure to improve public

health in the developing world. And because decades of neglect there

have rendered local hospitals, clinics, laboratories, medical schools,

and health talent dangerously deficient, much of the cash now flooding

the field is leaking away without result.

Moreover, in all too many cases, aid is tied to short-term numerical

targets such as increasing the number of people receiving specific

drugs, decreasing the number of pregnant women diagnosed with HIV (the

virus that causes AIDS), or increasing the quantity of bed nets handed

out to children to block disease-carrying mosquitoes. Few donors seem

to understand that it will take at least a full generation (if not two

or three) to substantially improve public health -- and that efforts

should focus less on particular diseases than on broad measures that

affect populations' general well-being.

The fact that the world is now short well over four million

health-care workers, moreover, is all too often ignored. As the

populations of the developed countries are aging and coming to require

ever more medical attention, they are sucking away local health talent

from developing countries. Already, one out of five practicing

physicians in the United States is foreign-trained, and a study

recently published in JAMA: The Journal of the American Medical

Association estimated that if current trends continue, by 2020 the

United States could face a shortage of up to 800,000 nurses and

200,000 doctors. Unless it and other wealthy nations radically

increase salaries and domestic training programs for physicians and

nurses, it is likely that within 15 years the majority of workers

staffing their hospitals will have been born and trained in poor and

middle-income countries. As such workers flood to the West, the

developing world will grow even more desperate.

Yet the visionary leadership required to tackle such problems is sadly

lacking. Over the last year, every major leadership position on the

global health landscape has turned over, creating an unprecedented

moment of strategic uncertainty. The untimely death last May of Dr.

Lee Jong-wook, director general of the World Health Organization

(WHO), forced a novel election process for his successor, prompting

health advocates worldwide to ask critical, long-ignored questions,

such as, Who should lead the fight against disease? Who should pay for

it? And what are the best strategies and tactics to adopt?

The answers have not been easy to come by. In November, China's Dr.

Margaret Chan was elected as Lee's successor. As Hong Kong's health

director, Chan had led her territory's responses to SARS and bird flu;

later she took the helm of the WHO's communicable diseases division.

But in statements following her election, Chan acknowledged that her

organization now faces serious competition and novel challenges. And

as of this writing, the Global Fund to Fight AIDS, Tuberculosis, and

Malaria remained without a new leader following a months-long

selection process that saw more than 300 candidates vie for the post

and the organization's board get mired in squabbles over the fund's

mission and future direction.

Few of the newly funded global health projects, meanwhile, have

built-in methods of assessing their efficacy or sustainability. Fewer

still have ever scaled up beyond initial pilot stages. And nearly all

have been designed, managed, and executed by residents of the wealthy

world (albeit in cooperation with local personnel and agencies). Many

of the most successful programs are executed by foreign NGOs and

academic groups, operating with almost no government interference

inside weak or failed states. Virtually no provisions exist to allow

the world's poor to say what they want, decide which projects serve

their needs, or adopt local innovations. And nearly all programs lack

exit strategies or safeguards against the dependency of local governments.

As a result, the health world is fast approaching a fork in the road.

The years ahead could witness spectacular improvements in the health

of billions of people, driven by a grand public and private effort

comparable to the Marshall Plan -- or they could see poor societies

pushed into even deeper trouble, in yet another tale of well-intended

foreign meddling gone awry. Which outcome will emerge depends on

whether it is possible to expand the developing world's local talent

pool of health workers, restore and improve crumbling national and

global health infrastructures, and devise effective local and

international systems for disease prevention and treatment.

SHOW ME THE MONEY

The recent surge in funding started as a direct consequence of the

HIV/AIDS pandemic. For decades, public health experts had been

confronted with the profound disparities in care that separated the

developed world from the developing one. Health workers hated that

inequity but tended to accept it as a fact of life, given that health

concerns were nested in larger issues of poverty and development.

Western AIDS activists, doctors, and scientists, however, tended to

have little experience with the developing world and were thus shocked

when they discovered these inequities. And they reacted with vocal

outrage.

The revolution started at an international AIDS meeting in Vancouver,

Canada, in 1996. Scientists presented exhilarating evidence that a

combination of anti-HIV drugs (known as antiretrovirals, or ARVs)

could dramatically reduce the spread of the virus inside the bodies of

infected people and make it possible for them to live long lives.

Practically overnight, tens of thousands of infected men and women in

wealthy countries started the new treatments, and by mid-1997, the

visible horrors of AIDS had almost disappeared from the United States

and Europe.

But the drugs, then priced at about $14,000 per year and requiring an

additional $5,000 a year for tests and medical visits, were

unaffordable for most of the world's HIV-positive population. So

between 1997 and 2000, a worldwide activist movement slowly developed

to address this problem by putting pressure on drug companies to lower

their prices or allow the generic manufacture of the new medicines.

The activists demanded that the Clinton administration and its

counterparts in the G-8, the group of advanced industrial nations,

pony up money to buy ARVs and donate them to poor countries. And by

1999, total donations for health-related programs (including HIV/AIDS

treatment) in sub-Saharan Africa hit $865 million -- up more than

tenfold in just three years.

In 2000, some 20,000 activists, scientists, doctors, and patients

gathered in Durban, South Africa, for another international AIDS

conference. There, South Africa's former president, Mandela,

defined the issue of ARV access in moral terms, making it clear that

the world should not permit the poor of Harare, Lagos, or Hanoi to die

for lack of treatments that were keeping the rich of London, New York,

and Paris alive. The World Bank economist Mead Over told the gathering

that donations to developing countries for dealing with HIV/AIDS had

reached $300 million in 1999 -- 0.5 percent of all development

assistance. But he characterized that sum as " pathetic, " claiming that

the HIV/AIDS pandemic was costing African countries roughly $5 billion

annually in direct medical care and indirect losses in labor and

productivity.

In 2001, a group of 128 Harvard University faculty members led by the

economist Sachs estimated that fewer than 40,000 sub-Saharan

Africans were receiving ARVs, even though some 25 million in the

region were infected with HIV and perhaps 600,000 of them needed the

drugs immediately. Natsios, then director of the U.S. Agency

for International Development (USAID), dismissed the idea of

distributing such drugs, telling the House International Relations

Committee that Africans could not take the proper combinations of

drugs in the proper sequences because they did not have clocks or

watches and lacked a proper concept of time. The Harvard faculty group

labeled Natsios' comments racist and insisted that, as Sachs put it,

all the alleged obstacles to widespread HIV/AIDS treatment in poor

countries " either don't exist or can be overcome, " and that three

million people in Africa could be put on ARVs by the end of 2005 at " a

cost of $1.1 billion per year for the first two to three years, then

$3.3 billion to $5.5 billion per year by Year five. "

Sachs added that the appropriate annual foreign-aid budget for

malaria, TB, and pediatric respiratory and diarrheal diseases was

about $11 billion; support for AIDS orphans ought to top $1 billion

per year; and HIV/AIDS prevention could be tackled for $3 billion per

year. In other words, for well under $20 billion a year, most of it

targeting sub-Saharan Africa, the world could mount a serious global

health drive.

What seemed a brazen request then has now, just five years later,

actually been eclipsed. HIV/AIDS assistance has effectively

spearheaded a larger global public health agenda. The Harvard group's

claim that three million Africans could easily be put on ARVs by the

end of 2005 proved overoptimistic: the WHO's " 3 by 5 Initiative "

failed to meet half of the three million target, even combining all

poor and middle-income nations and not just those in Africa.

Nevertheless, driven by the HIV/AIDS pandemic, a marvelous momentum

for health assistance has been built and shows no signs of abating.

MORE, MORE, MORE

In recent years, the generosity of individuals, corporations, and

foundations in the United States has grown by staggering proportions.

As of August 2006, in its six years of existence, the Bill and Melinda

Gates Foundation had given away $6.6 billion for global health

programs. Of that total, nearly $2 billion had been spent on programs

aimed at TB and HIV/AIDS and other sexually transmitted diseases.

Between 1995 and 2005, total giving by all U.S. charitable foundations

tripled, and the portion of money dedicated to international projects

soared 80 percent, with global health representing more than a third

of that sum. Independent of their government, Americans donated $7.4

billion for disaster relief in 2005 and $22.4 billion for domestic and

foreign health programs and research.

Meanwhile, the Bush administration increased its overseas development

assistance from $11.4 billion in 2001 to $27.5 billion in 2005, with

support for HIV/AIDS and other health programs representing the lion's

share of support unrelated to Iraq or Afghanistan. And in his 2003

State of the Union address, President W. Bush called for the

creation of a $15 billion, five-year program to tackle HIV/AIDS, TB,

and malaria. Approved by Congress that May, the President's Emergency

Plan for AIDS Relief (PEPFAR) involves assistance from the United

States to 16 nations, aimed primarily at providing ARVs for people

infected with HIV. Roughly $8.5 billion has been spent to date.

PEPFAR's goals are ambitious and include placing two million people on

ARVs and ten million more in some form of care by early 2008. As of

March 2006, an estimated 561,000 people were receiving ARVs through

PEPFAR-funded programs.

The surge in giving has not just come from the United States, however.

Overseas development assistance from every one of the nations in the

Organization for Economic ation and Development (OECD)

skyrocketed between 2001 and 2005, with health making up the largest

portion of the increase. And in 2002, a unique funding-dispersal

mechanism was created, independent of both the UN system and any

government: the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

The fund receives support from governments, philanthropies, and a

variety of corporate-donation schemes. Since its birth, it has

approved $6.6 billion in proposals and dispersed $2.9 billion toward

them. More than a fifth of those funds have gone to four nations:

China, Ethiopia, Tanzania, and Zambia. The fund estimates that it now

provides 20 percent of all global support for HIV/AIDS programs and 66

percent of the funding for efforts to combat TB and malaria.

The World Bank, for its part, took little interest in health issues in

its early decades, thinking that health would improve in tandem with

general economic development, which it was the bank's mission to

promote. Under the leadership of McNamara (which ran from 1968

to 1981), however, the bank slowly increased direct investment in

targeted health projects, such as the attempted elimination of river

blindness in West Africa. By the end of the 1980s, many economists

were beginning to recognize that disease in tropical and desperately

poor countries was itself a critical impediment to development and

prosperity, and in 1993 the bank formally announced its change of

heart in its annual World Development Report. The bank steadily

increased its health spending in the following decade, reaching $3.4

billion in 2003 before falling back to $2.1 billion in 2006, with $87

million of that spent on HIV/AIDS, TB, and malaria programs and $250

million on child and maternal health. The bank, along with the

International Monetary Fund (IMF), the OECD, and the G-8, has also

recently forgiven the debts of many poor nations hard-hit by AIDS and

other diseases, with the proviso that the governments in question

spend what would otherwise have gone for debt payments on key public

services, including health, instead.

When the Asian tsunami struck in December 2004, the world witnessed a

profound level of globalized generosity, with an estimated $7 billion

being donated to NGOs, churches, and governments, largely by

individuals. Although health programs garnered only a small percentage

of that largess, many of the organizations that are key global health

players were significantly bolstered by the funds.

In January 2006, as the threat of avian influenza spread, 35 nations

pledged $1.9 billion toward research and control efforts in hopes of

staving off a global pandemic. Since then, several G-8 nations,

particularly the United States, have made additional funding available

to bolster epidemiological surveillance and disease-control activities

in Southeast Asia and elsewhere.

And poor nations themselves, finally, have stepped up their own health

spending, partly in response to criticism that they were

underallocating public funds for social services. In the 1990s, for

example, sub-Saharan African countries typically spent less than 3

percent of their budgets on health. By 2003, in contrast, Tanzania

spent nearly 13 percent of its national budget on health-related goods

and services; the Central African Republic, Namibia, and Zambia each

spent around 12 percent of their budgets on health; and in Mozambique,

Swaziland, and Uganda, the figure was around 11 percent.

For most humanitarian and health-related NGOs, in turn, the surge in

global health spending has been a huge boon, driving expansion in both

the number of organizations and the scope and depth of their

operations. By one reliable estimate, there are now more than 60,000

AIDS-related NGOs alone, and there are even more for global health

more generally. In fact, ministers of health in poor countries now

express frustration over their inability to track the operations of

foreign organizations operating on their soil, ensure those

organizations are delivering services in sync with government policies

and priorities, and avoid duplication in resource-scarce areas.

PIPE DREAMS

One might think that with all this money on the table, the solutions

to many global health problems would at least now be in sight. But one

would be wrong. Most funds come with strings attached and must be

spent according to donors' priorities, politics, and values. And the

largest levels of donations are propelled by mass emotional responses,

such as to the Asian tsunami. Still more money is needed, on a regular

basis and without restrictions on the uses to which it is put. But

even if such resources were to materialize, major obstacles would

still stand in the way of their doing much lasting good.

One problem is that not all the funds appropriated end up being spent

effectively. In an analysis prepared for the second annual meeting of

the Clinton Global Initiative, in September 2006, Dalberg Global

Development Advisors concluded that much current aid spending is

trapped in bureaucracies and multilateral banks. Simply stripping

layers of financing bureaucracy and improving health-delivery systems,

the firm argued, could effectively release an additional 15-30 percent

of the capital provided for HIV/AIDS, TB, and malaria programs.

A 2006 World Bank report, meanwhile, estimated that about half of all

funds donated for health efforts in sub-Saharan Africa never reach the

clinics and hospitals at the end of the line. According to the bank,

money leaks out in the form of payments to ghost employees, padded

prices for transport and warehousing, the siphoning off of drugs to

the black market, and the sale of counterfeit -- often dangerous --

medications. In Ghana, for example, where such corruption is

particularly rampant, an amazing 80 percent of donor funds get

diverted from their intended purposes.

Another problem is the lack of coordination of donor activities.

Improving global health will take more funds than any single donor can

provide, and oversight and guidance require the skills of the many,

not the talents of a few compartmentalized in the offices of various

groups and agencies. In practice, moreover, donors often function as

competitors, and the only organization with the political credibility

to compel cooperative thinking is the WHO. Yet, as Harvard

University's Murray points out, the WGO itself is

dependent on donors, who give it much more for disease-specific

programs than they do for its core budget. If the WHO stopped chasing

such funds, Murray argues, it could go back to concentrating on its

true mission of providing objective expert advice and strategic guidance.

This points to yet another problem, which is that aid is almost always

" stovepiped " down narrow channels relating to a particular program or

disease. From an operational perspective, this means that a government

may receive considerable funds to support, for example, an

ARV-distribution program for mothers and children living in the

nation's capital. But the same government may have no financial

capacity to support basic maternal and infant health programs, either

in the same capital or in the country as a whole. So HIV-positive

mothers are given drugs to hold their infection at bay and prevent

passage of the virus to their babies but still cannot obtain even the

most rudimentary of obstetric and gynecological care or infant

immunizations.

Stovepiping tends to reflect the interests and concerns of the donors,

not the recipients. Diseases and health conditions that enjoy a

temporary spotlight in rich countries garner the most attention and

money. This means that advocacy, the whims of foundations, and the

particular concerns of wealthy individuals and governments drive

practically the entire global public health effort. Today the top

three killers in most poor countries are maternal death around

childbirth and pediatric respiratory and intestinal infections leading

to death from pulmonary failure or uncontrolled diarrhea. But few

women's rights groups put safe pregnancy near the top of their list of

priorities, and there is no dysentery lobby or celebrity attention

given to coughing babies.

The HIV/AIDS pandemic, meanwhile, continues to be the primary driver

of global concern and action about health. At the 2006 International

AIDS Conference, former U.S. President Bill Clinton suggested that

HIV/AIDS programs would end up helping all other health initiatives.

" If you first develop the health infrastructure throughout the whole

country, particularly in Africa, to deal with AIDS, " Clinton argued,

" you will increase the infrastructure of dealing with maternal and

child health, malaria, and TB. Then I think you have to look at

nutrition, water, and sanitation. All these things, when you build it

up, you'll be helping to promote economic development and alleviate

poverty. "

But the experience of bringing ARV treatment to Haiti argues against

Clinton's analysis. The past several years have witnessed the

successful provision of antiretroviral treatment to more than 5,000

needy Haitians, and between 2002 and 2006, the prevalence of HIV in

the country plummeted from six percent to three percent. But during

the same period, Haiti actually went backward on every other health

indicator.

Part of the problem is that most of global HIV/AIDS-related funding

goes to stand-alone programs: HIV testing sites, hospices and

orphanages for people affected by AIDS, ARV-dispersal stations,

HIV/AIDS education projects, and the like. Because of discrimination

against people infected with HIV, public health systems have been

reluctant to incorporate HIV/AIDS-related programs into general care.

The resulting segregation has reinforced the anti-HIV stigma and

helped create cadres of health-care workers who function largely

independently from countries' other health-related systems. Far from

lifting all boats, as Clinton claims, efforts to combat HIV/AIDS have

so far managed to bring more money to the field but have not always

had much beneficial impact on public health outside their own niche.

DIAMONDS IN THE ROUGH

Arguably the best example of what is possible when forces align

properly can be found in the tiny African nation of Botswana. In

August 2000, the Gates Foundation, the pharmaceutical companies Merck

and Bristol-Myers Squibb, and the Harvard AIDS Initiative announced

the launching of an HIV/AIDS treatment program in collaboration with

the government of Botswana. At the time, Botswana had the highest HIV

infection rate in the world, estimated to exceed 37 percent of the

population between the ages of 15 and 40. The goal of the new program

was to put every single one of Botswana's infected citizens in

treatment and to give ARVs to all who were at an advanced stage of the

disease. Merck donated its anti-HIV drugs, Bristol-Myers Squibb

discounted its, Merck and the Gates Foundation subsidized the effort

to the tune of $100 million, and Harvard helped the Botswanan

government design its program.

When the collaboration was announced, the target looked easily

attainable, thanks to its top-level political support in Botswana, the

plentiful money that would come from both the donors and the country's

diamond wealth, the free medicine, and the sage guidance of Merck and

Harvard. Unlike most of its neighbors, Botswana had an excellent

highway system, sound general infrastructure, and a growing middle

class. Furthermore, Botswana's population of 1.5 million was

concentrated in the capital city of Gaborone. The national

unemployment rate was 24 percent -- high by Western standards but the

lowest in sub-Saharan Africa. The conditions looked so propitious, in

fact, that some activists charged that the parties involved had picked

an overly easy target and that the entire scheme was little more than

a publicity stunt, concocted by the drug companies in the hopes of

deflecting criticism over their global pricing policies for AIDS drugs.

But it soon became apparent that even comparatively wealthy Botswana

lacked sufficient health-care workers or a sound enough medical

infrastructure to implement the program. The country had no medical

school: all its physicians were foreign trained or immigrants. And

although Botswana did have a nursing school, it still suffered an

acute nursing shortage because South Africa and the United Kingdom

were actively recruiting its English-speaking graduates. By 2005, the

country was losing 60 percent of its newly trained health-care workers

annually to emigration. (In the most egregious case, in 2004 a

British-based company set up shop in a fancy Gaborone hotel and, in a

single day, recruited 50 nurses to work in the United Kingdom.)

By 2002, the once-starry-eyed foreigners and their counterparts in

Botswana's government had realized that before they could start

handing out ARVs, they would have to build laboratories and clinics,

recruit doctors from abroad, and train other health-care personnel.

President Festus Mogae asked the U.S. Peace Corps to send doctors and

nurses. Late in the game, in 2004, the PEPFAR program got involved and

started working to keep HIV out of local hospitals' blood supplies and

to build a network of HIV testing sites.

After five years of preparation, in 2005 the rollout of HIV treatment

commenced. By early 2006, the program had reached its goal of treating

55,000 people (out of an estimated HIV-positive population of 280,000)

with ARVs. The program is now the largest such chronic-care operation

-- at least per capita -- in the world. And if it works, Botswana's

government will be saddled with the care of these patients for decades

to come -- something that might be sustainable if the soil there

continues to yield diamonds and the number of people newly infected

with HIV drops dramatically.

But Kwame Ampomah, a Ghana-born official for the Joint UN Program on

HIV/AIDS, based in Gaborone, now frets that prevention efforts are not

having much success. As of 2005, the incidence of new cases was rising

eight percent annually. Many patients on ARVs may develop liver

problems and fall prey to drug-resistant HIV strains. Ndwapi Ndwapi, a

U.S.-trained doctor who works at Princess Marina Hospital, in

Gaborone, and handles more of the government's HIV/AIDS patients than

anyone else, also frets about the lack of effective prevention

efforts. In slums such as Naledi, he points out, there are more bars

than churches and schools combined. The community shares latrines,

water pumps, alcohol -- and HIV. Ndawpi says Botswana's future rests

on its ability to fully integrate HIV/AIDS care into the general

health-care system, so that it no longer draws away scarce doctors and

nurses for HIV/AIDS-only care. If this cannot be accomplished, he

warns, the country's entire health-care system could collapse.

Botswana is still clearly somewhat of a success story, but it is also

a precariously balanced one and an effort that will be difficult to

replicate elsewhere. Ampomah says that other countries might be able

to achieve good results by following a similar model, but " it requires

transparency, and a strong sense of nationalism by leaders, not

tribalism. You need leaders who don't build palaces on the Riviera.

You need a clear health system with equity that is not donor-driven.

Everything is unique to Botswana: there is a sane leadership system in

Gaborone. So in Kenya today maybe the elite can get ARVs with their

illicit funds, but not the rest of the country. You need a complete

package. If the government is corrupt, if everyone is stealing money,

then it will not work. So there is a very limited number of African

countries that could replicate the Botswana experience. " And despite

the country's HIV/AIDS achievements and the nation's diamond wealth,

life expectancy for children born in Botswana today is still less than

34 years, according to CIA estimates.

BRAIN DRAIN

As in Haiti, even as money has poured into Ghana for HIV/AIDS and

malaria programs, the country has moved backward on other health

markers. Prenatal care, maternal health programs, the treatment of

guinea worm, measles vaccination efforts -- all have declined as the

country has shifted its health-care workers to the better-funded

projects and lost physicians to jobs in the wealthy world. A survey of

Ghana's health-care facilities in 2002 found that 72 percent of all

clinics and hospitals were unable to provide the full range of

expected services due to a lack of sufficient personnel. Forty-three

percent were unable to provide full child immunizations; 77 percent

were unable to provide 24-hour emergency services and round-the-clock

safe deliveries for women in childbirth. According to Dr. Ken Sagoe,

of the Ghana Health Service, these statistics represent a severe

deterioration in Ghana's health capacity. Sagoe also points out that

604 out of 871 medical officers trained in the country between 1993

and 2002 now practice overseas.

Zimbabwe, similarly, trained 1,200 doctors during the 1990s, but only

360 remain in the country today. In Kadoma, eight years ago there was

one nurse for every 700 residents; today there is one for every 7,500.

In 1980, the country was able to fill 90 percent of its nursing

positions nationwide; today only 30 percent are filled. Guinea-Bissau

has plenty of donated ARV supplies for its people, but the drugs are

cooking in a hot dockside warehouse because the country lacks doctors

to distribute them. In Zambia, only 50 of the 600 doctors trained over

the last 40 years remain today. Mozambique's health minister says that

AIDS is killing the country's health-care workers faster than they can

be recruited and trained: by 2010, the country will have lost 6,000

lab technicians to the pandemic. A study by the International Labor

Organization estimates that 18-41 percent of the health-care labor

force in Africa is infected with HIV. If they do not receive ARV

therapy, these doctors, nurses, and technicians will die, ushering in

a rapid collapse of the very health systems on which HIV/AIDS programs

depend.

Schouten, HIV coordinator for the Malawi Ministry of Health,

notes that of the country's 12 million people, 90,000 have already

died from AIDS and 930,000 people are now infected with HIV. Over the

last five years, the government has lost 53 percent of its health

administrators, 64 percent of its nurses, and 85 percent of its

physicians -- mostly to foreign NGOs, largely funded by the U.S. or

the British government or the Gates Foundation, which can easily

outbid the ministry for the services of local health talent. Schouten

is now steering a $270 million plan, supported by PEPFAR, to use

financial incentives and training to bring back half of the lost

health-care workers within five years; nearly all of these

professionals will be put to use distributing ARVs. But nothing is

being done to replace the health-care workers who once dealt with

malaria, dysentery, vaccination programs, maternal health, and other

issues that lack activist constituencies.

Ibrahim Mohammed, who heads an effort similar to Schouten's in Kenya,

says his nation lost 15 percent of its health work force in the years

between 1994 and 2001 but has only found donor support to rebuild

personnel for HIV/AIDS efforts; all other disease programs in the

country continue to deteriorate. Kenya's minister of health, Charity

Kaluki Ngilu, says that life expectancy has dropped in her country,

from a 1963 level of 63 years to a mere 47 years today for men and 43

years for women. In most of the world, male life expectancy is lower

than female, but in Kenya women suffer a terrible risk of dying in

childbirth, giving men an edge in survival. Although AIDS has

certainly taken a toll in Kenya, Ngilu primarily blames plummeting

life expectancy on former President arap Moi, who kept Kenyan

spending on health down to a mere $6.50 per capita annually. Today,

Kenya spends $14.20 per capita on health annually -- still an

appallingly low number. The country's public health and medical

systems are a shambles. Over the last ten years, the country has lost

1,670 physicians and 3,900 nurses to emigration, and thousands more

nurses have retired from their profession.

Data from international migration-tracking organizations show that

health professionals from poor countries worldwide are increasingly

abandoning their homes and their professions to take menial jobs in

wealthy countries. Morale is low all over the developing world, where

doctors and nurses have the knowledge to save lives but lack the

tools. Where AIDS and drug-resistant TB now burn through populations

like forest fires, health-care workers say that the absence of

medicines and other supplies leaves them feeling more like hospice and

mortuary workers than healers.

Compounding the problem are the recruitment activities of Western NGOs

and OECD-supported programs inside poor countries, which poach local

talent. To help comply with financial and reporting requirements

imposed by the IMF, the World Bank, and other donors, these programs

are also soaking up the pool of local economists, accountants, and

translators. The U.S. Congress imposed a number of limitations on

PEPFAR spending, including a ceiling for health-care-worker training

of $1 million per country. PEPFAR is prohibited from directly topping

off salaries to match government pay levels. But PEPFAR-funded

programs, UN agencies, other rich-country government agencies, and

NGOs routinely augment the base salaries of local staff with benefits

such as housing and education subsidies, frequently bringing their

employees' effective wages to a hundred times what they could earn at

government-run clinics.

USAID's Kent Hill says that this trend is " a horrendous dilemma " that

causes " immense pain " in poor countries. But without tough guidelines

or some sort of moral consensus among UN agencies, NGOs, and donors,

it is hard to see what will slow the drain of talent from

already-stressed ministries of health.

GOING DUTCH?

The most commonly suggested solution to the problematic pay

differential between the wages offered by local governments and those

offered by international programs is to bolster the salaries of local

officials. But this move would be enormously expensive (perhaps

totaling $2 billion over the next five years, according to one

estimate) and might not work, because of the problems that stem from

injecting too much outside capital into local economies.

In a recent macroeconomic analysis, the UN Development Program (UNDP)

noted that international spending on HIV/AIDS programs in poor

countries doubled between 2002 and 2004. Soon it will have doubled

again. For poor countries, this escalation means that by the end of

2007, HIV/AIDS spending could command up to ten percent of their GDPs.

And that is before donors even begin to address the health-care-worker

crisis or provide subsidies to offset NGO salaries.

There are three concerns regarding such dramatic escalations in

external funding: the so-called Dutch disease, inflation and other

economic problems, and the deterioration of national control. The UNDP

is at great pains to dismiss the potential of Dutch disease, a term

used by economists to describe situations in which the spending of

externally derived funds so exceeds domestic private-sector and

manufacturing investment that a country's economy is destabilized.

UNDP officials argue that these risks can be controlled through

careful monetary management, but not all observers are as sanguine.

Some analysts, meanwhile, insist that massive infusions of foreign

cash into the public sector undermine local manufacturing and economic

development. Thus, Arvind Subramanian, of the IMF, points out that all

the best talent in Mozambique and Uganda is tied up in what he calls

" the aid industry, " and Radelet, of the Center for Global

Development, says that foreign-aid efforts suck all the air out of

local innovation and entrepreneurship. A more immediate concern is

that raising salaries for health-care workers and managers directly

involved in HIV/AIDS and other health programs will lead to salary

boosts in other public sectors and spawn inflation in the countries in

question. This would widen the gap between the rich and the poor,

pushing the costs of staples beyond the reach of many citizens. If not

carefully managed, the influx of cash could exacerbate such conditions

as malnutrition and homelessness while undermining any possibility

that local industries could eventually grow and support themselves

through competitive exports.

Regardless of whether these problems proliferate, it is curious that

even the most ardent capitalist nations funnel few if any resources

toward local industries and profit centers related to health.

Ministries of health in poor countries face increasing competition

from NGOs and relief agencies but almost none from their local private

sectors. This should be troubling, because if no locals can profit

legitimately from any aspect of health care, it is unlikely that poor

countries will ever be able to escape dependency on foreign aid.

Finally, major influxes of foreign funding can raise important

questions about national control and the skewing of health-care

policies toward foreign rather than domestic priorities. Many

governments and activists complain that the U.S. government, in

particular, already exerts too much control over the design and

emphasis of local HIV/AIDS programs. This objection is especially

strong regarding HIV-prevention programs, with claims that the Bush

administration has pushed abstinence, fidelity, and faith-based

programs at the expense of locally generated condom- and

needle-distribution efforts.

Donor states need to find ways not only to solve the human resource

crisis inside poor countries but also to decrease their own dependency

on foreign health-care workers. In 2002, stinging from the harsh

criticism leveled against the recruitment practices of the NHS (the

United Kingdom's National Health Service) in Africa, the United

Kingdom passed the Commonwealth Code of Practice for the International

Recruitment of Health Workers, designed to encourage increased

domestic health-care training and eliminate recruitment in poor

countries without the full approval of host governments. British

officials argue that although the code has limited efficacy, it makes

a contribution by setting out guidelines for best practices regarding

the recruitment and migration of health-care personnel. No such code

exists in the United States, in the EU more generally, or in Asia --

but it should.

Unfortunately, the U.S. Congress has gone in the opposite direction,

acceding to pressure from the private health-care sector and inserting

immigration-control exemptions for health-care personnel into recent

legislation. In 2005, Congress set aside 50,000 special immigration

visas for nurses willing to work in U.S. hospitals. The set-aside was

used up by early 2006, and Senator Sam Brownback (R-Kans.) then

sponsored legislation eliminating all caps on the immigration of

nurses. The legislation offers no compensation to the countries from

which the nurses would come -- countries such as China, India, Kenya,

Nigeria, the Philippines, and the English-speaking Caribbean nations.

American nursing schools reject more than 150,000 applicants every

year, due less to the applicants' poor qualifications than to a lack

of openings. If it fixed this problem, the United States could be

entirely self-sufficient in nursing. So why is it failing to do so?

Because too few people want to be nursing professors, given that the

salaries for full-time nurses are higher. Yet every year Congress has

refused to pass bills that would provide federal support to

underfunded public nursing schools, which would augment professors'

salaries and allow the colleges to accept more applicants. Similar

(although more complex) forms of federal support could lead to

dramatic increases in the domestic training of doctors and other

health-care personnel.

Jim Leach, an outgoing Republican member of the House of

Representatives from Iowa, has proposed something called the Global

Health Services Corps, which would allocate roughly $250 million per

year to support 500 American physicians working abroad in poor

countries. And outgoing Senator Bill Frist (R-Tenn.), who volunteers

his services as a cardiologist to poor countries for two weeks each

year, has proposed federal support for sending American doctors to

poor countries for short trips, during which they might serve as

surgeons or medical consultants.

Although it is laudable that some American medical professionals are

willing to volunteer their time abroad, the personnel crisis in the

developing world will not be dealt with until the United States and

other wealthy nations clean up their own houses. OECD nations should

offer enough support for their domestic health-care training programs

to ensure that their countries' future medical needs can be filled

with indigenous personnel. And all donor programs in the developing

world, whether from OECD governments or NGOs and foundations, should

have built into their funding parameters ample money to cover the

training and salaries of enough new local health-care personnel to

carry out the projects in question, so that they do not drain talent

from other local needs in both the public and the private sectors.

WOMEN AND CHILDREN FIRST

Instead of setting a hodgepodge of targets aimed at fighting single

diseases, the world health community should focus on achieving two

basic goals: increased maternal survival and increased overall life

expectancy. Why? Because if these two markers rise, it means a

population's other health problems are also improving. And if these

two markers do not rise, improvements in disease-specific areas will

ultimately mean little for a population's general health and well-being.

Dr. Francis Omaswa, leader of the Global Health Workforce Alliance --

a WHO-affiliated coalition -- argues that in his home country of

Zambia, which has lost half of its physicians to emigration over

recent years, " maternal mortality is just unspeakable. " When doctors

and nurses leave a health system, he notes, the first death marker to

skyrocket is the number of women who die in childbirth. " Maternal

death is the biggest challenge in strengthening health systems, "

Omaswa says. " If we can get maternal health services to perform, then

we are very nearly perfecting the entire health system. "

Maternal mortality data is a very sensitive surrogate for the overall

status of health-care systems since pregnant women survive where safe,

clean, round-the-clock surgical facilities are staffed with

well-trained personnel and supplied with ample sterile equipment and

antibiotics. If new mothers thrive, it means that the health-care

system is working, and the opposite is also true.

Life expectancy, meanwhile, is a good surrogate for child survival and

essential public health services. Where the water is safe to drink,

mosquito populations are under control, immunization is routinely

available and delivered with sterile syringes, and food is nutritional

and affordable, children thrive. If any one of those factors is

absent, large percentages of children perish before their fifth

birthdays. Although adult deaths from AIDS and TB are pushing life

expectancies down in some African countries, the major driver of life

expectancy is child survival. And global gaps in life expectancy have

widened over the last ten years. In the longest-lived society, Japan,

a girl who was born in 2004 has a life expectancy of 86 years, a boy

79 years. But in Zimbabwe, that girl would have a life expectancy of

34 years, the boy 37.

The OECD and the G-8 should thus shift their targets, recognizing that

vanquishing AIDS, TB, and malaria are best understood not simply as

tasks in themselves but also as essential components of these two

larger goals. No health program should be funded without considering

whether it could, as managed, end up worsening the targeted life

expectancy and maternal health goals, no matter what its impacts on

the incidence or mortality rate of particular diseases.

Focusing on maternal health and life expectancy would also broaden the

potential impact of foreign aid on public diplomacy. For example,

seven Islamic nations (Afghanistan, Egypt, Iraq, Pakistan, Somalia,

Sudan, and Yemen) lose a combined 1.4 million children under the age

of five every year to entirely preventable diseases. These countries

also have some of the highest maternal mortality rates in the world.

The global focus on HIV/AIDS offers little to these nations, where the

disease is not prevalent. By setting more encompassing goals,

government agencies such as USAID and its British counterpart could

both save lives in these nations and give them a legitimate reason to

believe that they are welcome members of the global health movement.

Legislatures in the major donor nations should consider how the

current targeting requirements they place on their funding may have

adverse outcomes. For example, the U.S. Congress and its counterparts

in Europe and Canada have mandated HIV/AIDS programs that set specific

targets for the number of people who should receive ARVs, be placed in

orphan-care centers, obtain condoms, and the like. If these targets

are achievable only by robbing local health-care workers from

pediatric and general health programs, they may well do more harm than

good, and should be changed or eliminated.

In the philanthropic world, targeting is often even narrower, and the

demand for immediate empirical evidence of success is now the norm.

From the Gates Foundation on down to small family foundations and

individual donors, there is an urgent need to rethink the concept of

accountability. Funders have a duty to establish the efficacy of the

programs they support, and that may require use of very specific data

to monitor success or failure. But it is essential that philanthropic

donors review the relationship between the pressure they place on

recipients to achieve their narrow targets and the possible

deleterious outcomes for life expectancy and maternal health due to

the diversion of local health-care personnel and research talent.

SYSTEMS AND SUSTAINABILITY

Perched along the verdant hillsides of South Africa's KwaZulu-Natal

Province are tin-roofed mud-and-wood houses, so minimal that they

almost seem to shiver in the winter winds. An observant eye will spot

bits of carved stone laying flat among the weeds a few steps from the

round houses, under which lay the deceased. The stones are visible

evidence of a terrifying death toll, as this Zulu region may well have

the highest HIV prevalence rate in the world.

At the top of one hill in the Vulindlela area resides Chief Inkosi

Zondi. A quiet man in his early 40s, Zondi shakes his head over the

AIDS horror. " We can say there are 40,000 people in my 18

subdistricts, " he says. " Ten thousand have died. So about 25 percent

of the population has died. " In this rugged area, only about ten

percent of the adults have formal employment, and few young people

have much hope of a reasonable future. Funerals are the most

commonplace form of social gathering. Law and order are unraveling,

despite Chief Zondi's best efforts, because the police and the

soldiers are also dying of AIDS.

In such a setting, it seems obvious that pouring funds into local

clinics and hospitals to prevent and treat HIV/AIDS should be the top

priority. For what could be more important that stopping the carnage?

But HIV does not spread in a vacuum. In the very South African

communities in which it flourishes, another deadly scourge has

emerged: XDR-TB, a strain of TB so horribly mutated as to be resistant

to all available antibiotics. Spreading most rapidly among people

whose bodies are weakened by HIV, this form of TB, which is currently

almost always lethal, endangers communities all over the world. In

August 2006, researchers first announced the discovery of XDR-TB in

KwaZulu-Natal, and since then outbreaks have been identified in nine

other South African provinces and across the southern part of the

continent more generally. The emergence of XDR-TB in KwaZulu-Natal was

no doubt linked to the sorry state of the region's general health

system, where TB treatment was so poorly handled that only a third of

those treated for regular TB completed the antibiotic therapy. Failed

therapy often promotes the emergence of drug-resistant strains.

There is also an intimate relationship between HIV and malaria,

particularly for pregnant women: being infected with one exacerbates

cases of the other. Physicians administering ARVs in West Africa have

noticed a resurgence of clinical leprosy and hepatitis C, as latent

infections paradoxically surge in patients whose HIV is controlled by

medicine. HIV-positive children face a greater risk of dying from

vaccine-preventable diseases, such as measles, polio, and typhoid

fever, if they have not been immunized than do those nonimmunized

children without HIV. But if financial constraints force health-care

workers to reuse syringes for a mass vaccination campaign in a

community with a Vulindlela-like HIV prevalence, they will almost

certainly spread HIV among the patients they vaccinate. And if the

surgical instruments in clinics and hospitals are inadequately

sterilized or the blood-bank system lacks proper testing, HIV can

easily spread to the general population (as has happened in Canada,

France, Japan, Kazakhstan, Libya, Romania, and elsewhere).

As concern regarding the threat of pandemic influenza has risen

worldwide over the last two years, so has spending to bolster the

capacities of poor countries to control infected animal populations,

spot and rapidly identify human flu cases, and isolate and treat the

people infected. It has become increasingly obvious to the donor

nations that these tasks are nearly impossible to perform reliably in

countries that lack adequate numbers of veterinarians, public health

experts, laboratory scientists, and health-care workers. Moreover,

countries need the capacity to coordinate the efforts of all these

players, which requires the existence of a public health infrastructure.

At a minimum, therefore, donors and UN agencies should strive to

integrate their infectious-disease programs into general public health

systems. Some smaller NGOs have had success with community-based

models, but this needs to become the norm. Stovepiping should yield to

a far more generalized effort to raise the ability of the entire world

to prevent, recognize, control, and treat infectious diseases -- and

then move on to do the same for chronic killers such as diabetes and

heart disease in the long term. Tactically, all aspects of prevention

and treatment should be part of an integrated effort, drawing from

countries' finite pools of health talent to tackle all monsters at

once, rather than dueling separately with individual dragons.

de Ferranti, of the Brookings Institution, reckons that meeting

serious health goals -- such as getting eight million more people on

ARVs while bringing life expectancies in poor countries up to at least

the level of middle-income nations and reducing maternal mortality by

15-20 percent -- will cost about $70 billion a year, or more than

triple the current spending.

Even if such funds could be raised and deployed, however, for the

increased spending to be effective, the structures of global public

health provision would have to undergo a transformation. As Tore

Godal, who used to run the neglected-diseases program at the WHO,

recently wrote in Nature, " There is currently no systemic approach

that is designed to match essential needs with the resources that are

actually available. " He called for a strategic framework that could

guide both donations and actions, with donors thinking from the start

about how to build up the capabilities in poor countries in order to

eventually transfer operations to local control -- to develop exit

strategies, in other words, so as to avoid either abrupt abandonment

of worthwhile programs or perpetual hemorrhaging of foreign aid.

In the current framework, such as it is, improving global health means

putting nations on the dole -- a $20 billion annual charity program.

But that must change. Donors and those working on the ground must

figure out how to build not only effective local health

infrastructures but also local industries, franchises, and other

profit centers that can sustain and thrive from increased

health-related spending. For the day will come in every country when

the charity eases off and programs collapse, and unless workable local

institutions have already been established, little will remain to show

for all of the current frenzied activity.

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As a thought experiment, the Council on Foreign Relations' Global

Health Program has conceived of Doc-in-a-Box, a prototype of a

delivery system for the prevention and treatment of infectious

diseases. The idea is to convert abandoned shipping containers into

compact transportable clinics suitable for use throughout the

developing world.

Shipping containers are durable structures manufactured according to

universal standardized specifications and are able to be transported

practically anywhere via ships, railroads, and trucks. Because of

trade imbalances, moreover, used containers are piling up at ports

worldwide, abandoned for scrap. Engineers at Rensselaer Polytechnic

Institute converted a sample used container into a prototype

Doc-in-a-Box for about $5,000, including shipping. It was wired for

electricity and fully lit and featured a water filtration system, a

corrugated tin roofing system equipped with louvers for protection

during inclement weather, a newly tiled floor, and conventional doors

and windows. Given economies of scale and with the conversions

performed in the developing world rather than New York, it is

estimated that large numbers of Doc-in-a-Boxes could be produced and

delivered for about $1,500 each.

Staffed by paramedics, the boxes would be designed for the prevention,

diagnosis, and treatment of all major infectious diseases. Each would

be linked to a central hub via wireless communications, with its

performance and inventory needs monitored by nurses and doctors.

Governments, donors, and NGOs could choose from a variety of models

with customizable options, ordering paramedic training modules,

supplies, and systems-management equipment as needed. Doc-in-a-Boxes

could operate under a franchise model, with the paramedics involved

realizing profits based on the volume and quality of their operations.

Franchises could be located in areas now grossly underserved by health

clinics and hospitals, thus extending health-care opportunities

without generating competitive pressure for existing facilities.

On a global scale, with tens of thousands of Doc-in-a-Boxes in place,

the system would be able to track and respond to changing needs on the

ground. It would generate incentives to pull rapid diagnostics,

easy-to-take medicines, new types of vaccines, and novel prevention

tools out of the pipelines of biotechnology and pharmaceutical

companies. Supplies could be purchased in bulk, guaranteeing low

per-unit costs. And the sorts of Fortune 500 companies that now belong

to the Global Business Coalition on HIV/ AIDS, TB, and Malaria would

be able to provide services and advice.

Over time, Doc-in-a-Boxes could emerge as sustainable local

businesses, providing desperately needed health-care services to poor

communities while generating investment and employment, like branches

of Starbucks or Mc's.

http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-\

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